Certification Form For Listing On Tennessees Directory

State of Tennessee Office of the Attorney General and Reporter Revenue Section Tobacco Enforcement Division Post Office Box 20207 Nashville, TN 37202-0207 Annual Certification Form for Listing on Tennessee's Directory Pursuant to Tenn. Code Ann. §§ 67-4-2601 et seq. Check appropriate response: Certification Year: __________ [ ] Initial Directory Certification Application ­ Tobacco Product Manufacturer is not currently listed on the Tennessee's Directory of Approved Tobacco Product Manufacturers. [ ] Supplemental Directory Certification ­ Change of information provided to the Attorney General and the Department of Revenue (change of information must be submitted at least 30 days prior to change or no more than 30 days after discovery of inaccurate, incomplete or misleading information). Reason: _____________________________________________________________________________ ____________________________________________________________________________________ [ ] Annual Directory Certification ­ Due April 30 for continuation of listing on Tennessee's Directory of Approved Tobacco Product Manufacturers. Please type or legibly print in permanent blue ink. Use additional pages only when necessary. Part 1. General Information 1. Applicant/Tobacco Product Manufacturer Identification. Applicant Name: Contact Person: Street Address: City/State/Zip: Mailing Address if different from above: City/State/Zip: Telephone Number (include country code): E-Mail Address: Website Address: Name of Person Completing Certification: Title of Person Completing Certification: Facsimile Number (include country code): FEIN: Title: Revised January 2016 Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Annual Directory Certification 2. The Tobacco Product Manufacturer identified above, as of the date of this Certification is: A Participating Manufacturer - OR A Non-Participating Manufacturer in full compliance with Tennessee Tobacco Manufacturers' Escrow Fund Act of 1999, Tenn. Code Ann. §§ 47-31-101 et seq., including having made all required deposits into a Qualified Escrow Fund since the effective date of the Tennessee Tobacco Manufacturers' Escrow Fund Act of 1999 and any rules and regulations promulgated there under. APPLICANT MUST ALSO COMPLETE EITHER THE PM OR NPM INFORMATION REQUEST FORM AND SUBMIT ALONG WITH THIS FORM. 3. Identify the attorney authorized to represent you regarding your Certification application for listing on the Tennessee Directory. If you do not have an attorney please indicate "Not Applicable." Attorney Name: Law Firm: Address: City/State/ZIP: Telephone Number: E-mail Address: Facsimile Number: Not Applicable 4. Identify the person authorized to provide information to the State of Tennessee or receive information from the State of Tennessee regarding your Certification application for listing on the Tennessee Directory. Name and Title: Company: Address: City/State/ZIP: Telephone Number: E-mail Address: Facsimile Number: Part 2. Indian Tribe/Nation Affiliation 5. Please answer the following questions by placing an "X" in the box marked yes or no after each question: A. Is applicant a federally recognized Indian Tribe/Nation or a legal entity formed under tribal law? Yes No Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Annual Directory Certification B. Is applicant owned by a member(s) of an Indian Tribe/Nation and located on Tribal land? Yes Does applicant have or make any claim of Tribal sovereign immunity? Yes No No No C. D. Is applicant owned in whole or in part by any government or government agency? Yes If your answer to any of the questions above is "Yes", please contact the Office of the Attorney General, Revenue Section, Tobacco Enforcement Division, P. O. Box 20207, Nashville, TN 37202-0207, to make arrangements to execute any required waivers of sovereign immunity in order to be listed and/or remain on the Directory of Approved Tobacco Manufacturers in Tennessee. Part 3. Deliveries into Tennessee 6. 7. Is the Applicant in compliance with the Prevent All Cigarette Trafficking Act? Yes No Does Applicant advertise, offer for sale, sell, transfer or ship for profit cigarettes, roll-your-own ("RYO") tobacco, or smokeless tobacco into Tennessee through interstate commerce? Yes Has Applicant filed a PACT Act Registration form with the TN Dept. of Revenue? Has Applicant filed PACT Reports for all shipments into Tennessee? Yes Yes No No No 8. 9. Part 4. Additional Information 10. Is your company a non-participating manufacturer located outside of the United States? Has your company, any of its affiliates, officers, directors or owners ever pled guilty or nolo contendere to or been found guilty of a crime relating to the reporting, distribution, sale or taxation of cigarettes or other tobacco products? Yes No 11. Yes No 12. If you answered "Yes" to question #11, provide the name of person(s) or entity, the crime, the jurisdiction in which this took place, and the date of the conviction or the plea. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 13. Has your company or any of its affiliates ever been removed from any state's (or other political subdivision's) directory of approved tobacco product manufacturers? Yes No Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com Annual Directory Certification 14. If you answered "Yes" to question #13, identify the state(s) or political subdivision(s) and the reason for the removal. _____________________________________________________________________________________ _____________________________________________________________________________________ 15. Has any state, or other political subdivision, claimed that your company or any of its affiliates is escrow deficient for units sold in the state of political subdivision? Yes No If you answered "Yes" to question #15, identify the state(s) or political subdivision(s), and the nature of the escrow deficiency. _____________________________________________________________________________________ _____________________________________________________________________________________ 16. Part 5. Br